Article SCIENCE PROGRESS

Science Progress

Euthanasia in adults with 2021, Vol. 104(3) 1–23

Ó The Author(s) 2021

psychiatric conditions: A Article reuse guidelines:

sagepub.com/journals-permissions

descriptive study of the DOI: 10.1177/00368504211029775

journals.sagepub.com/home/sci

experiences of Belgian
psychiatrists

Monica Verhofstadt1,2 , Kurt Audenaert3,

Kris Van den Broeck4, Luc Deliens1,2, Freddy
Mortier1,5, Koen Titeca6,7, Dirk De Bacquer2 and
Kenneth Chambaere1,2
1
Vrije Universiteit Brussel and Ghent University, Ghent, Belgium
2
Department Public Health and Primary Care, Ghent University, Gent, Belgium
3
Department of Psychiatry, Ghent University Hospital, Gent, Belgium
4
Collaborative Antwerp Psychiatric Research Institute, Antwerp University, Antwerp,
Belgium
5
Bioethics Institute Ghent, Ghent University, Ghent, Belgium
6
Department of Psychiatry, General Hospital Groeninge, Courtrai, Belgium
7
ULteam, End-of-Life Consultation Centre, Wemmel, Brussels, Belgium

Abstract
To investigate the experience of psychiatrists who completed assessment procedures of euthana-
sia requests from adults with psychiatric conditions (APC) over the last 12 months. Between
November 2018 and April 2019 a cross-sectional survey was sent to a sample of 753 psychiatrists
affiliated with Belgian organisations of psychiatrists to gather detailed information on their latest
experience with a completed euthanasia assessment procedure, irrespective of its outcome (i.e.
euthanasia being performed or not). Information on 46 unique cases revealed that most APC suf-
fered from comorbid psychiatric and/or somatic disorders, and had received different kinds of
treatment for many years prior to their euthanasia request. Existential suffering was the main rea-
son for the request. The entire procedure spanned an average of 14 months, and an average of
13.5 months in the 23 cases that culminated in the performance of euthanasia. In all cases, the
entire procedure entailed multidisciplinary consultations, including with family and friends.
Psychiatrists reported fewer difficulties in assessing due care criteria related to the APC’s self-

Corresponding author:
Monica Verhofstadt, Department Public Health and Primary Care, Ghent University, Corneel Heymanslaan
10, 6K3, Ghent 9000, Belgium.
Email: monica.verhofstadt@vub.be

Creative Commons Non Commercial CC BY-NC: This article is distributed under the terms of the Creative
Commons Attribution-NonCommercial 4.0 License (https://creativecommons.org/licenses/by-nc/4.0/)
which permits non-commercial use, reproduction and distribution of the work without further permission provided the original
work is attributed as specified on the SAGE and Open Access pages (https://us.sagepub.com/en-us/nam/open-access-at-sage).
2 Science Progress

contemplation – for example, unbearable suffering on top of the due care criteria related to their
medical condition; incurability due to lack of reasonable treatment perspectives. In a few cases in
which euthanasia was the outcome, not all legal criteria were fulfilled in the reporting physicians’
opinions. Both positive and negative experiences of the assessment procedure were reported:
for example, reduced suicide risk for the APC; an emotional burden and a feeling of being pres-
sured for the psychiatrist. This study confirms that euthanasia assessment in APC entails a lengthy
process with diverse complexities, and psychiatrists require support in more than one respect if
the assessments are to be handled adequately. Thorough evaluation of current guidelines is rec-
ommended: that is, to what extent the guidelines sufficiently address the complexities around
(e.g.) assessing legal criteria or involving relatives. We formulate various avenues for further
research to build on this study’s insights and to fill remaining knowledge gaps.

Keywords
Euthanasia, mental disorders, assisted suicide, psychiatry, survey study

Introduction
Adults with psychiatric conditions (APC) can be found legally eligible for euthana-
sia in Belgium if all the legal criteria as listed in Box 1 are fulfilled.1 As some contest
whether and when an APC can meet all legal requirements, the practice remains
subject to controversy, fiercely dividing clinical and ethical opinions,2–7 and some-
times resulting in legal examination.8,9 Meanwhile, the proportion of euthanasia
cases in APC within all reported performed euthanasias remains small but has
increased from 0.2% during the period 2002–2007 to 2.1% in 201510,11 before
declining to 1.2% in 2017.12
Empirical evidence regarding Belgian euthanasia practice with APC is limited.
To our knowledge, only two retrospective studies exist, which were limited in scope
because one only reported about performed euthanasia cases, and the other only
reported about requests from a single practice.10,13 One study revealed that the con-
sultation process takes an average of 9 months, involving an average of four consul-
tation sessions with multiple actors (e.g. patient, clinicians, family and friends). The
study also showed that, whilst 48 of 100 euthanasia requests were accepted, 73%
had been carried out, 21% had been withdrawn voluntarily, 2% had to be with-
drawn due to imprisonment, and 4% of the requestors died by suicide.13.
The performed euthanasia cases concerned adults of different ages, mostly
women, suffering from multiple chronic psychiatric disorders, mainly major depres-
sive and personality disorders.10,13
A recent Belgian survey study gauging psychiatrists’ attitudes and experiences
on this topic pointed out that psychiatrists struggle with these practices, due to the
difficulties of reconciling euthanasia assessment with the patient-psychiatrist rela-
tionship.14,15 In addition, almost three out of four Belgian psychiatrists question
the adequacy of euthanasia assessment in current practice, which is in line with pre-
vious Dutch studies that indicate dissension among physicians regarding whether
the legal criteria were/can be met.16–18
Verhofstadt et al. 3

So far, few Belgian studies have investigated the reasons that APC request
euthanasia, and none have focused in detail on the challenge of the assessment for
the psychiatrists involved. As psychiatric consultation is imperative and legally
mandatory for determining the APC’s eligibility for euthanasia, we in this study
use psychiatrists’ experiences to gain additional insights into current practices.
This study aimed to come to a description of completed euthanasia assessment
procedures by asking a large representative sample of psychiatrists about their
most recent experience during the last 12 months regarding: (1) the APC’s back-
ground in terms of diagnoses and treatment history; (2) the APC’s reasons for
requesting euthanasia; (3) the main characteristics of euthanasia assessment proce-
dures and finally, (4) the psychiatrists’ perceived difficulties and/or other experi-
ences regarding the assessment.

Methods
Study design and participants
Case-based data on individual APC’s completed euthanasia assessment procedures
were obtained through a cross-sectional survey of Belgian psychiatrists, consisting
of a paper-and-pencil and web survey. The survey was sent to 753 potential respon-
dents: 499 Flemish-speaking psychiatrists affiliated with the Flemish Psychiatry
Association (FPA), and 254 French-speaking psychiatrists of the Royal Society of
Mental Health of Belgium (SRMMB). The FPA’s members comprise an estimated
80%–90% of all psychiatrists active in the Flemish-speaking part of Belgium. No
estimated percentages could be given with regard to the SRMMB’s members, due
to a lack of current trustworthy registration of practitioners in the French-speaking
part of Belgium.
Only reports from psychiatrists working in Belgium and having been involved in
at least one completed euthanasia assessment procedure for an APC in the previous
12 months were included in the study.

Survey instrument
We based our questionnaire partly on an existing Dutch questionnaire.19 We vali-
dated the final instrument with a selected group of 15 psychiatrists and their trai-
nees for cognitive validation purposes (i.e. for participants to identify potential
problems regarding item interpretation, item redundancy, completeness of the sur-
vey, feasibility of generating correct answers and time estimation) and adjusted it
accordingly.
The survey was divided into two parts: one general part to be completed by every
psychiatrist, whether or not they had been involved in concrete evaluation of eutha-
nasia requests (see Appendix A in OSF); and one part focussing on their last con-
crete involvement with a completed euthanasia assessment procedure during the
past 12 months, if applicable (see Appendix B in OSF). This study reports on their
4 Science Progress

last concrete involvement (see Appendix C in OSF for the English version of the
questionnaire).
The survey questions were preceded by the following sentence: ‘The questions
below relate to your most recent experience with a completed euthanasia procedure
(regardless of its final outcome) of an adult patient, predominantly suffering from
a psychiatric condition, other than dementia, in the past 12 months’. Capitals were
used to make clear that APC encompass the following two adult patient groups:
(1) patients whose euthanasia request is predominantly based on suffering caused
solely by their psychiatric conditions, other than dementia; and (2) patients whose
euthanasia request is predominantly based on suffering caused primarily by their
psychiatric conditions, and secondarily by somatic comorbid conditions.

Procedure
Data collection. Data were collected between November 2018 and April 2019. The
FPA members were first sent a link to LimeSurvey’s online platform.20 Non-
responders received a first reminder via e-mail 2 weeks after the initial invitation
and a second, including a paper-and-pencil version by post, 3 weeks after. The
SRMMB members were only sent the paper-and-pencil version, by post, as the
SRMMB database only contained postal addresses, and non-responders received a
reminder 2 weeks afterwards (See OSF, Appendix D, for a more detailed research
protocol).

Data management. Data were imported from LimeSurvey into SPSS, cleaned
according to the principles of a predetermined data analysis plan (See OSF,
Appendix E), and completed with the cleaned data gathered from the returned
paper surveys.

Statistical analysis. No sample size calculation/power analysis was done, as we

intended to survey the entire eligible professional group. As duplicate cases could
occur (i.e. the same individual euthanasia case being reported by at least two psy-
chiatrists), we performed a manual check to identify euthanasia cases with identical
or near-identical data by crossing the values of the following variables: (1) specific
characteristics of the responding psychiatrists (e.g. specific role in the euthanasia
procedure), (2) specific characteristics of the euthanasia procedure (e.g. the dura-
tion of the procedure, the number and nature of formal (and additional) advices
obtained, the final outcome) and (3) specific characteristics of the APC (eg. psy-
chiatric and somatic diagnoses, duration of the treatment trajectory). As the man-
ual check revealed no duplicates, all reported cases were included in this study. All
gathered data were analysed by means of standard descriptive statistics, including
data that describe the sample of responding psychiatrists. The answers to the open
question were used to elaborate further on the given responses by means of the-
matic analysis.
Verhofstadt et al. 5

Ethics. This research project was performed in accordance with the Declaration of
Helsinki and received ethical approval from the Medical Ethics Committee of the
Brussels University Hospital with reference BUN 143201837302 and the Medical
Ethics Committee of the Ghent University Hospital with reference 2018-1165.

Results
The appended flowchart in OSF illustrates the response sample procedure of
Belgian psychiatrists who filled out the optional part of the survey. The
Supplemental Material in OSF shows the characteristics of our sample of 46 psy-
chiatrists. Most were men (65%), mainly working in a private or group clinical
practice (63%) and/or psychiatric hospital care (63%) for more than 10 years
(91%).

Clinical characteristics for APC requesting euthanasia

As shown in Table 1, in 89% of the completed case questionnaires the APC’s psy-
chiatric disorders were specified with depressive disorders (N = 23) and personality
disorders (N = 18) being the most common. Nearly half of the APC (48%) suffered
from somatic co-morbidities, from chronic fatigue syndrome to Parkinson’s disease
to overall multi-morbidity. At their first consultation for euthanasia, 91% were in
treatment, most often including psychotropics (80%) and/or other medical drugs
(28%) and/or psychotherapy (67%). The mean and median length of treatment his-
tory were 11 and 7 years, respectively.
A similar picture emerges with regard to the euthanasia requests that culminated
in the performance of euthanasia (n = 23). These cases mainly concerned APC with
comorbid disorders (70%), and close to half (48%) suffered from severe physical
co-morbidities: for example, cancer and chronic pain-related problems, some of
which were related to injuries incurred by a previous suicide attempt. At the time
of their first consultation for euthanasia, all but one APC were in treatment. The
mean and median length of treatment history were 8 and 5 years, respectively, with
a minimum of 1 month and a maximum of 25 years.

Main reasons for requesting euthanasia

Most psychiatrists (87%) indicated more than 3 reasons for the request, with a
minimum of 1, a maximum of 12, and an average of 6–7. Table 2 lists the indicated
categories, in descending order of prevalence. No perspective for improvement
(87%), a very low level of quality of life, just being in ‘survival mode’ (72%), and
existential suffering (63%) were most often reported, and even to a greater extent
if the APC died by means of euthanasia (96%, 83% and 74%, respectively). In the
23 performed euthanasia cases, ‘No purpose left in life’ (78%) was also more often
indicated. When asked to report the two main reasons for euthanasia requests, the
most frequent were: existential suffering, and no perspective for improvement.
6 Science Progress

Table 1. Clinical characteristics of adults with psychiatric conditions with assessed euthanasia
requests.

All requests Euthanasia

(N = 46) cases (n = 23)

N (%)

Patient’s pathology
Specified psychiatric conditions 41 (89.1) 21 (91.3)
Depressive disorders 23 (50.0) 9 (42.8)
Personality disorders 18 (39.1) 7 (30.4)
Schizophrenia spectrum and 6 (13.0) 4 (17.4)
other psychotic disorders
Trauma- and stressor-related 6 (13.0) 2 (8.7)
disorders
Anxiety disorders 4 (8.7) 2 (8.7)
Bipolar and related disorders 3 (6.5) 2 (8.7)
Feeding and eating disorders 3 (6.5) 0 (0.0)
Neurodevelopment disorders 2 (4.3) 0 (0.0)
Substance-related and 1 (2.2) 1 (4.3)
addictive disorders
Unspecified psychiatric 5 (10.9) 2 (8.7)
conditions
Somatic co-diagnoses 22 (47.8) 11 (47.8)
Severe brain injury 5 (10.9) 2 (8.7)
Physical deterioration 3 (6.5) 1 (4.3)
Pain, incl. consequences of 3 (6.5) 3 (13.0)
failed suicide attempts
Palsy 2 (4.3) 1 (4.3)
Parkinson 2 (4.3) 1 (4.3)
Hearing problem 2 (4.3) 1 (4.3)
Chronic fatigue 2 (4.3) 1 (4.3)
syndrome/fibromyalgia
Diabetes/morbid obesitas 2 (4.3) 1 (4.3)
Cancer 1 (2.2) 1 (4.3)
Overall multimorbidity 1 (2.2) 1 (4.3)
Patient’s treatment history at
first consultation
No active treatmenta 4 (8.7) 1 (4.3)
Active treatment 42 (91.3) 22 (95.6)
Psychotropics 37 (80.4) 21 (91.3)
Other drugs 13 (28.3) 7 (30.4)
Psychotherapy 31 (67.4) 18 (78.3)
Other interventionsb 14 (30.4) 8 (34.8)
Length of the patient’s treatment history
Mean (SD) 10.6 years (9.8) 8 years (6.9)
Median (min-max) 7 years 5 years
(1 month–32 years) (1 month–25 years)
\1 year 5 (11.0) 2 (8.7)
(continued)
Verhofstadt et al. 7

Table 1. Continued

All requests Euthanasia

(N = 46) cases (n = 23)

N (%)

1–2 years 6 (13.0) 3 (13.0)

2–5 years 8 (17.3) 6 (26.1)
.5–10 years 5 (11.0) 3 (13.0)
10 + years 16 (34.7) 6 (26.1)
Missing 6 (13.0) 3 (13.0)
a
In two cases explained as follows: the patient did receive psychiatric treatment in the past.
b
Other interventions were specified as follows: neurosurgical treatment and/or electroconvulsive therapy,
ambulant and/or residential admittance in a psychiatric unit, nursing and/or other care in a psychiatric home
care setting, alternative psychotherapy, mobile team.

Whereas loneliness was ranked third in all reported cases, pain-related problems
closed the top three ranking with regard to the 23 performed euthanasia cases.
In addition, the open question yielded additional motives for the request:
namely, all types of fears other than suicide (e.g. potential repetitive traumatic
events), being finished with treatment (due to, for example, treatment resistance on
the level of the APC’s psychopathology, even if the APC is improving on the physi-
cal level), complex grief, self-hatred and financial difficulties.

Main characteristics of the APC’s euthanasia assessment procedure

Based on the answers of the responding psychiatrists, the mean and median length
of the euthanasia assessment procedure were 14 and 7 months, respectively, and if
the patient died by euthanasia, 13.5 and 6 months, with a minimum of 2 weeks and
a maximum of 5 years (see Table 3). The psychiatrist was usually (61%) the
patient’s treating physician. In all cases, other professionals were consulted, most
often the general practitioner (63%) and the psychiatrist’s colleagues (46%), and
to a greater extent when death by euthanasia was the outcome. Note that, even in
the case of performed euthanasia, the palliative care team was involved during the
euthanasia assessment procedure (21.7%). In addition, family and/or friends were
also often consulted (74%), and a third of these family and/or friends also during a
concluding session after a final decision (54%). When euthanasia was the outcome,
the APC’s social inner circle was consulted in almost all cases (91%), and in 43.5%
also after the final decision had been reached.
According to the respondents, the substantive due care criteria, as prescribed by
the law on euthanasia were fulfilled in 61%–89% of all cases and in 70%–96% of
performed euthanasia cases. The criteria ‘medical futility’, ‘incurability of the dis-
order’ and the ‘absence of reasonable therapeutic options’, were met to the lowest
degree (in 61%–65% of all cases, or in 67%–70% cases if corrected for missings).
8 Science Progress

Table 2. Reasons for requesting euthanasia in adults with psychiatric conditions.a

All requests Euthanasia

(N = 46) cases
(n = 23)

N (%)

Indicated reasons for requesting euthanasiab

No perspective for improvement 40 (87.0) 22 (95.6)
No quality of life, only in ‘survival mode’ 33 (71.7) 19 (82.6)
Existential suffering (suffering from life itself, meaninglessness) 29 (63.0) 17 (73.9)
Stalled on many life domains (work/relationships/...) 27 (58.7) 13 (56.5)
No purpose (left) in life 26 (56.5) 18 (78.3)
Feelings of depression 22 (47.8) 12 (52.2)
Loss of dignity 22 (47.8) 15 (65.2)
Loss of autonomy, control over own life 21 (45.7) 10 (43.5)
Loneliness 18 (39.1) 9 (39.1)
No (longer) wanting to be a burden 16 (34.8) 10 (43.5)
Gradual deterioration 16 (34.8) 10 (43.5)
Total exhaustion 10 (21.7) 6 (26.1)
Fear of suicide 9 (19.6) 4 (17.4)
Disability/immobility 9 (19.6) 5 (21.7)
Other (e.g. pain) 8 (17.4) 2 (8.7)
Indicated main reasons of the euthanasia request
Existential suffering 16 (34.8) 7 (30.4)
No perspective for improvement 11 (23.9) 7 (30.4)
Loneliness 7 (15.2) 2 (8.7)
No quality of life, only ‘surviving’ 6 (13.0) 4 (17.4)
Pain related problemsc 5 (10.9) 5 (21.7)
Fears 5 (10.9) 2 (8.7)
Feelings of depression 5 (10.9) 4 (17.4)
Gradual deterioration 5 (10.9) 3 (13.0)
Lack of purposes left in life 5 (10.9) 2 (8.7)
a
Psychiatrists could indicate as many predesignated categories as applicable.
b
The answers on the open question, no. 9: ‘In your opinion, what were the two main reasons for the patient
to request euthanasia?’ were tallied. If the answers did not fit one of the categories of question no. 8, it was
also coded and counted (missings: n = 3). This yielded additional motives for the patient’s euthanasia request,
namely: (1) all kinds of fears, other than the fear of suicide, for example: fear of repetitive traumatic events;
(2) being through with treatment due to for example, treatment resistance, even if the patient is improving
on the physical level; (3) complicated grief; (4) self-hatred; and (5) financial difficulties.
c
Some pain related problems were ascribed to the consequences of failed suicide attempts.

Note that, whereas the legal criterion ‘incurability of the disorder’ was considered
sufficiently met in 70% of all performed euthanasia cases (76% if corrected for
missings), its operationalised criterion (as suggested in the guidelines on how to
adequately assess euthanasia requests from APC) was considered sufficiently met
in 83%.
In four out of five cases, at least two legal advices were given or obtained, mostly
positive ones (70%). In all performed euthanasia cases, at least two positive advices
Verhofstadt et al. 9

Table 3. Characteristics of the euthanasia procedure in adults with psychiatric conditions.

All requests Euthanasia

(N = 46) cases
(n = 23)

N (%)

Duration of the euthanasia procedure

Mean (SD) 13.9 months 13.5 months
(16.2) (15.9)
Median (min-max) 7 months 6 months
(2 weeks–5 years) (2 weeks–5 years)
\1 month 2 (4.3) 2 (8.7)
1–2 months 2 (4.3) 0 (0.0)
2–6 months 11 (23.9) 5 (21.7)
6–12 months 11 (23.9) 6 (26.1)
1–2 years 7 (15.2) 4 (17.4)
.2 years 9 (19.5) 5 (21.7)
Missings 4 (8.7) 1 (4.3)
Involvement of professionals and
carers in the euthanasia procedure
Specific role of the psychiatrist in
the euthanasia procedurea
Treating physician (of the patient’s 28 (60.9) 15 (65.2)
psychopathology, not regarding the
euthanasia procedure)
Attending physician of the psychiatrist’s 10 (21.7) 5 (21.7)
own patient (actively assessing the
euthanasia request)
Attending physician of a patient 11 (23.9) 4 (17.4)
from a colleague-physician (idem)
Preliminary advising physician 5 (10.9) 3 (13.0)
Procedural advising physician 13 (28.3) 6 (26.1)
Performing physician 4 (8.7) 4 (17.4)
Involvement of other professionals
None 0 (0.0) 0 (0.0)
The patient’s general practitioner 29 (63.0) 18 (78.2)
Independent colleague-psychiatrist(s) 21 (45.7) 13 (56.5)
Independent LEIF-physician(s), 15 (32.6) 10 (43.5)
trained and experienced in end-of-life care issues
Psychologist(s) 15 (32.6) 8 (34.8)
Nurses 11 (23.9) 9 (39.1)
Other physicians of the patient 9 (19.6) 4 (17.4)
Independent physicians of 9 (19.6) 4 (17.4)
specialised end-of-life centres
Ethics committee 8 (17.4) 6 (26.1)
Palliative care team 7 (15.2) 5 (21.7)
(Psycho-)Social service(s) 4 (8.7) 3 (13.0)
Another internal advisory committee 3 (6.5) 3 (13.0)
Othersb 5 (10.9) 4 (17.4)
Involvement of family and/or friends
No, although the patient did 9 (19.6) 2 (8.7)
have family or friends
No, patient did not have family or friends 3 (6.5) 0 (0.0)
(continued)
10 Science Progress

Table 3. Continued

All requests Euthanasia

(N = 46) cases
(n = 23)

N (%)

Yes, during the euthanasia procedure 22 (47.8) 11 (47.8)

Yes, during and after the euthanasia procedure 12 (26.1) 10 (43.5)
Psychiatrists’ opinion on the substantive
due care criteria being fulfilled
Voluntary, sustained and repeated request 41 (89.2) 21 (91.3)
Unbearable suffering 40 (87.0)c 22 (95.6)
Mental competency 38 (82.6)c 20 (87.0)c
Incurability of the disorder 30 (65.2)e 16 (69.6)d
No reasonable therapeutic options left 29 (63.0)c 19 (82.6)
Medical futility 28 (60.9)f 18 (78.3)d
Outcomes of the procedure
Formal advices on the euthanasia requests
Yes, without additional advices 23 (53.5)h 8 (34.8)g
Yes, with additional advices obtained 15 (34.9)h 11 (47.8)g
No 3 (6.9) 0 (0.0)
Don’t know 2 (4.7) 0 (0.0)
Nature of advices given or obtainedc
Only positive advices 30 (65.2) 21 (91.3)
Only negative advices 8 (17.4) 0 (0.0)
Mixed positive and negative advices 2 (4.7) 1 (4.3)
Patient still alive?c
No, the patient died by means of euthanasia 23 (50.0) 23 (100)
No, the patient died otherwisei 5 (10.9)
Yes, the procedure is still on goingj 8 (17.4)
Yes, the patient had withdrawn the request 3 (6.5)
No idea (not informed) 6 (13.0)
a
Psychiatrists could indicate as many predesignated categories as applicable. For example, at the start or
during the course of a euthanasia assessment procedure, the treating physician can decide to also engage as
performing physician.
b
Others: patient’s treating physician (of the patient’s psychopathology), colleague-psychiatrists for informal
advice, the religious/spiritual caregiver’ at the affiliated psychiatric centre, members of the ambulant or
residential psychiatric care facility, or the case was distributed at the responsibility of the hospital in
question.
c
Missing n = 1.
d
Missing n = 2.
e
Missing n = 3.
f
Missing n = 4.
g
The number of advices was not specified in n = 3.
h
The number of advices was not specified in n = 4.
i
In some cases specified as death by suicide. In one case the patient died after having the euthanasia request
withdrawn.
j
In these cases, the assessment procedure is concluded but the final decision is not yet made or the practical
modalities are to be discussed, for example, the decision when or where to die.
Verhofstadt et al. 11

from other physicians were obtained, except in one case in which both positive and
negative advices were obtained. In five cases, in the responding psychiatrists’ opin-
ion, not all of the substantive due care criteria were sufficiently met. The APC’s
young age, remaining treatment options according to the state-of-the-art protocol,
as well as certain clinical conditions (i.e. personality or bipolar disorder) were
reported as contra-indications.
In cases in which the APC died otherwise – for example, suicide (data not
shown for reasons of privacy, as n = 5, and the cause of death is not reported in all
cases), negative advices were obtained more often, or the absence of hopelessness
or remaining reasonable treatment options were reported. In three of the latter
cases, psychiatrists reported an improvement in the medical condition due to a new
treatment programme.
As for outcomes, 61% of the APC died by means of euthanasia (50%) or other-
wise (e.g. suicide). In 26% of the cases, the APC were still alive. In 13%, the report-
ing psychiatrist was out of the loop regarding the final decision. One psychiatrist
reported two final outcomes, as the APC had withdrawn the euthanasia request a
few weeks prior to suicide.

Perceived difficulties and/or other experiences

As revealed in Table 4, difficulties in the adequate assessment of the substantive
due care criteria were in most cases related to the characteristics of the medical con-
dition. One-quarter of the psychiatrists that were involved in the 23 cases that cul-
minated in euthanasia reported having difficulties in the assessment of the legal
criteria ‘medical futility’ (26%) and ‘incurability of the disorder’ (22%), and with
its operationalised criterion ‘lack of reasonable therapeutic perspectives’ (26%).
Half of the psychiatrists (52%) reported feeling pressured by the APC to
approve euthanasia. When they felt pressured by the APC’s family or friends, this
concerned pressure to decide in favour (15%) or against (9%) approving the
APC’s request.
The whole assessment procedure posed a heavy emotional burden on the major-
ity of the psychiatrists (72% and 65% for those confronted with performed eutha-
nasia cases) and more than half of the psychiatrists (irrespective of the outcome)
sought emotional support to cope with it. Positive effects were also reported, such
as a lower suicide risk (57% and 60.9% for the ones that reported on performed
euthanasia cases).
Whereas the re-establishment of relationships between patient and significant
others was reported to a greater extent by the psychiatrists who reported on per-
formed euthanasia cases (39% vs 26%), new therapeutic opportunities were
reported to a lesser extent (9% vs 26%).
After conclusion of the procedure, the attitudes of the majority of the psychia-
trists (78%) towards euthanasia had not changed. If it had changed, most psychia-
trists reported that they were willing to engage in future euthanasia procedures,
albeit more carefully (e.g. by taking more time to reflect thoroughly on the request,
12 Science Progress

Table 4. Psychiatrists’ experiences or difficulties perceived during the assessment procedures

in adults with psychiatric conditions.

All requests Euthanasia

(N = 46) cases
(n = 23)
N (%)

Experienced difficulties in
assessing criteriaa
Lack of a reasonable 16 (34.8) 6 (26.1)
therapeutic perspective
Medical futility 15 (32.6)b 6 (26.1)
Incurability of the disorder 14 (30.4) 5 (21.7)
Unbearable suffering 9 (19.5) 1 (4.3)
Voluntary, sustained and 7 (15.2) 1 (4.3)
well-considered request
Mental competence 4 (8.6) 1 (4.3)
Experienced forms of pressure
Patient requesting euthanasia under 4 (8.7)c 1 (4.3)b
pressure from others
Pressure from the patient to 24 (52.2) 12 (52.2)
approve euthanasia
Pressure from patient’s family or 7 (15.2) 4 (17.4)
friends to approve euthanasia
Pressure from patient’s family or friends 4 (8.7)b 3 (13.0)
to reject the euthanasia request
Pressure from colleagues to reject 4 (8.7)c 1 (4.3)
the euthanasia request
Pressure from colleagues to 3 (6.5)c 3 (13.0)b
approve euthanasia
Pressure from the care institute to 2 (4.3)c 1 (4.3)b
reject the euthanasia request
Pressure from the care institute 0 (0.0)c 0 (0.0)b
to approve euthanasia
Other experiences
High emotional burden for yourself 33 (71.7) 15 (65.2)
A lowered risk of suicide with the patient 26 (56.5) 14 (60.9)
New therapeutic opportunities 12 (26.1) 2 (8.7)
with the patient
Re-establishment of relationships between 12 (26.1) 9 (39.1)
patient and significant others
Fellow patients also requesting 4 (8.7) 2 (8.7)
euthanasiab
Emotional support sought?
No 21 (45.7) 10 (43.5)
Yes, inner personal circle 14 (30.4) 9 (39.1)
Yes, colleagues 17 (37.0) 8 (34.8)
Yes, external professional help 1 (2.2) 1 (4.3)
Yes, others 1 (2.2) 1 (4.3)
(continued)
Verhofstadt et al. 13

Table 4. Continued

All requests Euthanasia

(N = 46) cases
(n = 23)
N (%)

Attitude towards psychiatric euthanasia

changed after this specific case?
No 36 (78.3) 17 (73.9)
Yesd 10 (21.7) 6 (26.1)
a
This variable was measured by means of a Likert-Scale using scores from 1 to 5, with minimum score = 1
(None) and maximum score = 5 (A great deal). In this table, only the N and % of scores ˜4 are presented.
b
Missing: n = 1.
c
Missing: n = 2.
d
In some cases the change in attitudes was specified as follows: in 6/10 cases (or 4/6 cases when n = 23) the
attitude towards euthanasia in APC changed in a (n) even more risk-aversive way. In 2/10 cases (or 1/6 cases
when n = 23) the attitudes changed in a (n even) more favourable way. Finally, in 2/10 cases (or 1/6 cases
when n = 23) mixed attitudes due to both favourable and unfavourable experiences were reported.

adopting more inter- and supervisions, being less quick to refer to end-of-life con-
sultation centres). Others looked back upon the experience more favourably and
described it as beautiful and enriching for all actors involved, including for
themselves.
In addition, qualitative analysis of the answers to the open question ‘Would you
like to add any clarification or comments about this particular case?’ revealed that
some psychiatrists, irrespective of their change of mind, expressed the need for a
change in law, for example, implementation of more strict criteria for APC, per the
recommendations of the guidelines that were published in the year prior to the sur-
vey in order to make these recommendations legally enforceable.

Discussion
Summary of main results
Of all 46 completed euthanasia assessment procedures in APC, most concerned
patients who suffered from comorbid psychiatric and/or somatic disorders and who
had received different forms of treatment for many years prior to their request.
‘Existential suffering’ and ‘no prospect of improvement’ were reported as the main
reasons for the request. In all cases, the entire procedure entailed multidisciplinary
consultations, including family and friends.
Psychiatrists reported fewer difficulties in assessing due care criteria related
directly to the APC themselves than in assessing the criteria related to their medical
condition (e.g. incurability). Both positive and negative experiences during the
assessment procedure were reported: for example, a reduced suicide risk for the
APC versus emotional burden and feeling pressured by the APC and/or their rela-
tives for the psychiatrist.
14 Science Progress

As for the final outcomes, half of the completed euthanasia assessment proce-
dures culminated in the performance of euthanasia after at least two legally
required advices were obtained, all positive bar one.

Interpretation of findings
Our study has shown the complexity of euthanasia assessment procedures in differ-
ent regards. One noteworthy illustration is that euthanasia assessment procedures
may span multiple months or even years. This can be related to the APC not being
expected to die in the foreseeable future, and that some mental disorders tend to
fluctuate in severity or even resolve over time, which warrants extreme caution.
The majority of the APC, irrespective of the outcome, have been treated for their
conditions for many years, giving psychiatrists involved in the assessment a lot of
ground to cover. In line with Dutch results,19,21 our study confirms that, when
euthanasia was performed, the assessment procedure took an average of more than
1 year, with a few conspicuous exceptions. In two cases, assessment was reported
as concluded in \2 weeks. This would be a violation of the Law, which requires a
minimum waiting period of 1 month between the formal request for, and the per-
formance of, euthanasia. However, this is highly unlikely to occur in practice; it is
more plausible that the question was accidentally answered from the sole perspec-
tive of the individual psychiatrist and their task-specific involvement, instead of for
the entire assessment procedure.
Another marked result is that, in 5 of 23 performed euthanasia cases, not all of
the legal criteria had been sufficiently met in the responding psychiatrist’s percep-
tion. This may raise questions about the legality of some euthanasia cases in APC.
However, we have not gauged the opinion of the other clinicians involved in those
cases, and we do know that the necessary formal advices were obtained in all cases.
These cases again illustrate the complexity of the procedures and therefore the
likely lack of consensus between the physicians involved,14,15 which, according to
our study, primarily concerns the incurability of the condition and the lack of rea-
sonable perspectives for improvement.
The psychiatrists also reported specific challenges regarding euthanasia assess-
ment, in terms of the difficulties encountered in determining the extent to which the
legal criteria are met in APC cases.
In line with former studies, the APC present with various psychiatric and
somatic comorbidities.13 As comorbidity is perceived as an important challenge in
medicine in general,24,25 it also seems to pose a challenge in euthanasia assessment.
However, this study confirms former research,22,23 which maintains that the rea-
sons for the APC’s euthanasia request are not entirely dependent on clinical symp-
toms alone (e.g. loneliness) and that the APC’s problems are deeply rooted and
branched into various aspects of the patient’s past and current life. These findings
point to the responsibility of our societies (and thus not only of the field of psy-
chiatry) to address the problems that confront APC such as loneliness. This multi-
dimensional picture undoubtedly compounds the difficulties for psychiatrists in
Verhofstadt et al. 15

determining (e.g.) the incurability of the APC’s condition and to what extent there
are reasonable treatment alternatives, which are reported in about 1 in 3 cases (and
which may lead to dissensions, as discussed above). Symptoms of psychiatric disor-
ders tend to change over time – even leading, in some cases, to remission and clini-
cal and/or social rehabilitation – and this underscores the challenge to
operationalising this legal criterion in the field of psychiatry, as stated in previous
studies.14,15 The question is whether or not the present guidelines are sufficient to
support psychiatrists in these assessments.
Relatively few psychiatrists (9%) reported difficulties in assessing another cen-
tral legal criterion – mental capacity – which is noteworthy given the predominant
focus on competence in clinical and societal debate. A marked finding is that some
respondents referred to specific diagnoses as contraindications for APC to be com-
petent, and therefore eligible for euthanasia, a much-debated issue of which the last
word has not yet been said.7,16,26,27 Ruling out APC for euthanasia on the basis of
a diagnostic label can be problematic, as diagnostic classification is often contested
due to low reliability and validity.28–30 Though the nature of (some) psychiatric
diagnoses may indeed affect mental capacity, it has been stressed in all Belgian
guidelines on euthanasia31 that this cannot be grounds to rule out all APC for
euthanasia by definition. In any case, utmost caution is needed; and the perceived
absence of mental competence in a few cases might suggest the need for a standar-
dised capacity evaluation. To our knowledge, only one Dutch and one Belgian
study on this topic have shown that the assessment of this criterion differs among
individual physicians (i.e. to some extent due to their personal values and belief
system),32 and, in some cases, seems even flawed, which has led to dissensions
among physicians on the evaluation outcome.17
Our study brought an underexposed issue to light: namely, the high emotional
strain on almost three quarters of the participating psychiatrists. Our findings sug-
gest that one source of such strain is that the whole euthanasia procedure can be
seen as a ‘balancing act’ in terms of suicide prevention on the one hand and taking
sufficient time for rigorous euthanasia assessment on the other. For example, both
reduced suicidality and opportunities for rehabilitation during euthanasia assess-
ment were reported, which is also in line with former research findings.13,19,22
Anecdotal accounts reveal that suicide risk may be one of the reasons responding
psychiatrists feel pressured by the APC into granting the request. Previous research
shows that some patients die by means of suicide, even when the euthanasia request
has been granted, which suggests that these APC perceived the euthanasia proce-
dure to be too long and/or too arduous.13,25 The relatively high number of negative
advices in this group would corroborate this interpretation. However, it is impor-
tant to note that we gauged neither for past suicide attempts nor for actual suicide
risk in this survey. As for the latter, other potential explanations need to be taken
into account: that is, for some, the euthanasia procedure itself might reduce the risk
of suicide for that period, but for others it could actually increase the risk of sui-
cide. Another likely source of strain is pressure coming from relatives, either to
approve or to deny the APC’s request.
16 Science Progress

That said, it remains unclear whether the support available to psychiatrists is

sufficient and which aspects of the assessment cause the most emotional strain.
Current research and guidelines predominantly emphasise the implementation of
the legal and due care criteria, thereby largely ignoring the moral and personal
challenges for psychiatrists themselves.

Implications for practice, policy and research

As for policy and practice, the finding that some legal criteria were not (suffi-
ciently) met in the perception of the psychiatrists involved seems to corroborate
concerns about whether requests are always assessed and monitored adequately
and rigorously.14
It is deemed quintessential to gauge whether, and to what extent, the recently
published guidelines33 have sufficiently addressed and effectively tackled the many
challenges regarding decision-making and the abovementioned moral dilemmas.
For example, the ‘incurability of the disorder’ criterion has been operationalised in
these guidelines, but there may be a need for further refinement, or maybe even for
an alternative legal term that better suits the field of psychiatry. The same could be
said about ‘reasonable state-of-the-art treatment options’ – with the inherent rela-
tive proximity of ‘therapeutic tenacity’ and ‘therapeutic negligence’ – in the context
of psychiatry’s lack of objective knowledge regarding prognoses and treatment out-
comes. Moreover, the guidelines provide very little on involving and dealing with
relatives, while our study revealed that they are often involved and can add pres-
sure on psychiatrists during the assessment. However, as most of the guidelines
were published just a few months prior to this survey, it is yet unclear whether the
psychiatrists were familiar with them.
In order to expand upon this study’s generated insights, the need for further
research is considerable. Qualitative in-depth research into the factors that might
further support and enable psychiatrists and other professionals in adequately
assessing such requests is needed. This will also allow us to gain deeper insight into
the emotional impact these procedures can have on psychiatrists, on the APC and
those close to them, and on the therapeutic relationship.34 Given that the psychia-
trists reported successful rehabilitation in some APC, future research should also
focus on protective factors – such as engagement in a supportive social network or
acquiring resilience and coping skills – that can lead to increased quality of life
which may decrease the wish to die. With regard to the ambiguity of law and the
difficulties of its implementation in psychiatric practice, especially in the most com-
plex cases, the research method of casuistry may help to address the unclear legal
and ethical challenges. Also, large-scale studies should provide more reliable esti-
mates of requests and granting rates and enable the factors influencing the out-
comes of the euthanasia requests to be identified. Of the 46 APC applying for
euthanasia in this study, two-thirds obtained at least two positive advices and could
be considered formally approved for euthanasia. This result may suggest a high
approval rate – but that is misleading, as prior evidence indicates that the vast
Verhofstadt et al. 17

majority of requests are denied, rejected, or withdrawn before a formal outcome is

reached.13,19,21,35,36 Moreover, obtaining two positive advices does not automati-
cally mean that the APC have been approved for euthanasia, as the physician
entrusted with the clarification of the APC’s euthanasia requests may seek to obtain
additional (i.e. more than the two legally required) advices. Lastly, future research
might also focus on examining the impact and consequences of ungranted requests
– as, for example, the APC might be left to their fate with their death ideation,
while their physicians refuse to engage in discussion about it.

Strengths and limitations

This is the first study to provide an in-depth analysis of the experiences of Belgian
psychiatrists regarding the complexity of euthanasia practice in adults with psychia-
tric conditions. It reveals new insights into many aspects of the assessment proce-
dure and the impact it has on the psychiatrists involved. We gathered information
on 46 assessed cases and 23 performed euthanasia cases predominantly based on
psychiatric disorders that were checked for uniqueness by crossing essential vari-
ables. As for representativeness, according to the latest official Euthanasia Review
Committee Report, 27 APC died in 2016 and 26 in 2017 by means of euthanasia12
(p. 46). Assuming that the numbers remained similar in the period of our survey,
this may suggest that our study comprises close to all euthanasia cases based on
psychiatric disorders. However, given the potential response and selection bias in
our study, we cannot make assertions about the representativeness of the captured
cases in relation to the entire euthanasia practice in psychiatry.
Though this analysis provides rich insights into psychiatrists’ practice and chal-
lenges in dealing with euthanasia requests from APC, the authors wish to stress that
the data do not readily allow for evaluation of: (a) the legality of performed eutha-
nasia cases, or (b) the factors predictive of requests leading to euthanasia.
Some results should be interpreted with caution due to the potential sources of
bias: response bias given low response rates, but also selection bias as we suspect
respondents often refrained from reporting about concluded cases where the APC
are still alive. Assuming that the psychiatrists were much more inclined to report
on euthanasia requests that have been carried out than on those put on hold, we
have thus not captured a large proportion of completed evaluations that have not
culminated in euthanasia.
This is supported by anecdotal evidence, and annual reports from clinical prac-
tice reveal that a large proportion of these patients put their procedure on hold
after 1 to 2 consultations.37 This combination of potential biases renders the inter-
pretation of half of the requests leading to euthanasia untrustworthy and overesti-
mated, all the more so considering existing sources reporting lower rates.19,21,38
Finally, and although the survey was pre-tested for cognitive validity, we cannot
exclude the possibility of misunderstandings remaining with regard to the interpre-
tation of individual items.
18 Science Progress

Conclusions
This study has revealed the complexity of euthanasia assessment in APC, due to
the variety of (comorbid) diagnoses and often severe somatic co-diagnoses, the
variety of reasons for requesting euthanasia (also appealing to the responsibility of
our society), the difficulties in assessing the legal and due care criteria, and the
emotional impact of euthanasia assessment on psychiatrists. Not only does it
involve people with long histories of medical diagnoses and treatment, but assess-
ment also requires a large amount of time. When the euthanasia request culmi-
nated in the performance of euthanasia, the entire procedure spanned an average
of 13 months (which is much longer than the legally required 1 month) and entailed
multidisciplinary consultations (e.g. psychologists, palliative care team), including
with family and friends (which is not required by law). Our findings indicate that
psychiatrists require support in more than one respect if euthanasia requests by
APC are to be handled adequately: To what extent can or do the guidelines pro-
vide answers to assessment complexities? Is there a need for specific education in
assessment? Are legal clarifications in order? Future (qualitative) research can aid
by focussing on the psychiatrists’ and the APC’s experiences and needs in this
regard.
Due to the considerable risk of bias, this analysis should be read as an account
of the types of cases and issues encountered in psychiatric euthanasia practice, and
not necessarily as a reflection of the entire psychiatric euthanasia assessment prac-
tice. A more robust mapping of euthanasia assessment procedures in APC would
be better achieved through studies with large reliable denominators generating esti-
mates of (e.g.) granting rates and insight into factors influencing the granting of
requests.

Acknowledgements
The authors wish to thank all participants for filling in the questionnaire. Major thanks to
FPA’s medical secretary, Anita Rys, for the time and effort spent on recruitment and fol-
low-up, logistical services and encouragement. We also want to acknowledge the 15 psychia-
trists and trainees of Ghent University Hospital’s Psychiatry Department for their feedback
during the cognitive validation phase of the survey questionnaire. We also wish to thank the
researchers of the End of Life Care Research Group who tested the web survey for technical
problems and time estimation. We would also like to acknowledge Filip Schriers and
Michelle Leisner for folding the paper-and-pencil surveys and putting them in envelopes.
Last but not least, we’d like to thank Jane Ruthven and William Wright for their help in fix-
ing our English language issues.

Author contributions
The article has been developed with contributions as follows: The survey was developed by
MV, KVB, KT, KA, LD and KC, and prof. dr. Joris Vandenberghe of the Flemish
Psychiatric Association (FPA). MV and KA arranged cognitive validation of the survey;
MV was responsible for the development of the online survey, whereas MV and KVB were
responsible for the practical and technical aspects of survey distribution; KVB and KT were
Verhofstadt et al. 19

responsible for communication management among the FPA members; MV, KA and KC
managed ethical approval; MV and KC managed data-collection, storage and analysis; MV
and KC were responsible for literature search and references, whereas MV, KVB, KA, LD,
DDB and KC were responsible for the methodology. All authors contributed to data-
interpretation and the writing of all sections, and performed a critical review and revision of
the final manuscript. All authors approved the final version of the manuscript.

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, author-
ship, and/or publication of this article.

Funding
The author(s) disclosed receipt of the following financial support for the research, author-
ship, and/or publication of this article: MV is funded by the Research Foundation Flanders
via research project (G017818N) and PhD fellowship (1162618N). The Study in the French-
speaking part of Belgium was funded by the Belgian Ministry of Social Affairs and Public
Health.

ORCID iD
Monica Verhofstadt https://orcid.org/0000-0002-6623-7444

Data access
This study is fully disclosed, except for the database for reasons of anonymity and privacy.
To access the supplementary materials, see the Open Science Framework repository at:
https://osf.io/cy297/.

Supplemental material
Supplemental material for this article is available online.

References
1. Belgian Official Gazette. Law of 28 May 2002 on Euthanasia. For an authoritative
English translation, see the Constitutional Court of Belgium (29 October 2015) 153/
2015. Brussels, http://www.const-court.be/public/e/2015/2015-153e.pdf (2002, accessed
12 July 2018).
2. Cheng M. Doctors clash over euthanasia for mentally ill. London, UK: Associated
Press, 2017. https://apnews.com/article/e44827 ae3daf471596546e924165d234
3. Braeckman J, Ravelingien A and Boudry M. ‘‘Don’t trivialize psychological suffering’’
(open response letter, translated by Trudo Lemmens), https://trudolemmens.
wordpress.com/2015/12/14/dont-trivialize-psychological-suffering/ (2015, accessed 14
December 2017).
20 Science Progress

4. Bazan A, Van de Vijver G and Lemmens W. ‘‘Remove Euthanasia on the basis of

purely psychological suffering from the legislation’’ (open letter, translated by Trudo
Lemmens), (2015). https://trudolemmens.wordpress.com/2015/12/09/translation-of-an-
open-letter-of-8-december-2015-by-belgian-psychiatrists-psychologists-philosophers-
and-others-re-psychological-suffering-in-belgian-euthanasia-legislation-translation/
(2015, accessed 1 June, 2020).
5. Gale C and Barak Y. Euthanasia, medically assisted dying or assisted suicide: time for
psychiatrists to say no. Australas Psychiatry 2020; 28(2): 160–163.
6. Schuklenk U. The ethical case against assisted euthanasia has not been made. J Thorac
Cardiovasc Surg 2015; 149: 1685–1686.
7. Rooney W, Schuklenk U and van de Vathorst S. Are concerns about irremediableness,
vulnerability, or competence sufficient to justify excluding all psychiatric patients from
medical aid in dying? Health Care Anal 2018; 26: 326–343.
8. Kulczyk P. The ECHR is looking into the abuses of euthanasia in Belgium. https://
eclj.org/euthanasia/echr/the-echr-is-looking-into-the-abuses-of-euthanasia-in-belgium
(2019, accessed 10 May, 2020).
9. Day M. Three Belgian doctors are investigated over euthanasia of woman with
Asperger’s. BMJ 2018; 363. (accessed 10 May, 2020).
10. Dierickx S, Deliens L, Cohen J, et al. Euthanasia for people with psychiatric disorders
or dementia in Belgium: analysis of officially reported cases. BMC Psychiatry 2017;
17(1): 203.
11. Federal Control and Evaluation Committee for Euthanasia. Seventh report to the
Belgian Parliament, 2016. Federal Control and Evaluation Committee for Euthanasia
(FederaleControle- enEvaluatieCommissieEuthanasie, FCECE), Brussels, Belgium.
https://leif.be/data/press-articles/FCEED_-_Verslag_Wetgevende_Kamers_-_periode_
2014-2015_25-10-16.pdf
12. Federal Control and Evaluation Committee for Euthanasia. Ninth report to the Belgian
Parliament, 2020. Federal Control and Evaluation Committee for Euthanasia
(FederaleControle- enEvaluatieCommissieEuthanasie, FCECE), Brussels, Belgium.
https://leif.be/data/press-articles/Wilsverklaringen/FCEE_-_Verslag_ 2020_cijfers_2018-
2019.pdf
13. Thienpont L, Verhofstadt M, Van Loon T, et al. Euthanasia requests, procedures and
outcomes for 100 Belgian patients suffering from psychiatric disorders: a retrospective,
descriptive study. BMJ Open 2015; 5(7): e007454.
14. Verhofstadt M, Audenaert K, Van den Broeck K, et al. Belgian psychiatrists’ attitudes
towards, and readiness to engage in, euthanasia assessment procedures with adults with
psychiatric conditions: a survey. BMC Psychiatr 2020. doi:10.1186/s12888-020-02775-x
15. Verhofstadt M, Audenaert K, Van den Broeck K, et al. The engagement of psychiatrists
in the assessment of euthanasia requests from psychiatric patients in Belgium: a survey
study. BMC Psychiatr 2020. doi:10.1186/s12888-020-02792-w
16. Nicolini M, Peteet JR, Donovan G, et al. Euthanasia and assisted suicide of persons
with psychiatric disorders: the challenge of personality disorders. Psychol Med 2020; 50:
575–582.
17. Doernberg SN, Peteet JR and Kim SYH. Capacity evaluations of psychiatric patients
requesting assisted death in the Netherlands. Psychosomatics 2016; 57(6): 556–565.
18. Kim SYH, De Vries RG and Peteet JR. Euthanasia and assisted suicide of patients with
psychiatric disorders in the Netherlands 2011 to 2014. JAMA Psychiatry 2016; 73(4):
362–368.
Verhofstadt et al. 21

19. Onwuteaka-Philipsen BD, Legemaate J, van der Heide A, et al. Derde Evaluatie Wet
Toetsing Levensbeëindiging Op Verzoek En Hulp Bij Zelfdoding. Den Haag: ZonMw;
2017. https://publicaties.zonmw.nl/derde-evaluatie-wet-toetsing-levensbeeindiging-op-
verzoek-en-hulp-bij-zelfdoding/.
20. LimeSurvey Project Team/Carsten Schmitz. LimeSurvey: an open source survey tool.
Hamburg, Germany: LimeSurvey Project Team, 2017.
21. Evenblij K, Pasman HRW, Pronk R, et al. Euthanasia and physician-assisted suicide in
patients suffering from psychiatric disorders: a cross-sectional study exploring the
experiences of Dutch psychiatrists. BMC Psychiatry 2019; 19: 74.
22. Verhofstadt M, Thienpont L and Peters G-JY. When unbearable suffering incites
psychiatric patients to request euthanasia: qualitative study. Br J Psychiatry 2017;
211(4): 238–245.
23. Dees M, Vernooij-Dassen M, Dekkers W, et al. Unbearable suffering of patients with a
request for euthanasia or physician-assisted suicide: an integrative review.
Psychooncology 2010; 19(4): 339–352.
24. Sartorious N. Comorbidity of mental and physical diseases: a main challenge for
medicine of the 21st century. Shanghai Arch Psychiatry 2013; 25: 68–69.
25. Rai D, Stansfeld S, Weich S, et al. (2016) Comorbidity in mental and physical illness.’
In: McManus S, Bebbington P, Jenkins R, Brugha T (eds.) Mental health and wellbeing
in England:Adult Psychiatric Morbidity Survey 2014. Leeds: NHS Digital. https://
pure.ulster.ac.uk/ws/files/11652887/apms-2014-comorbidity.pdf
26. Broome MR and de Cates A. Choosing death in depression: a commentary on
‘Treatment-resistant major depressive disorder and assisted dying’. J Med Ethics 2015;
41: 586–587.
27. Schuklenk U and van de Vathorst S. Treatment-resistant major depressive disorder and
assisted dying. J Med Ethics 2015; 41: 577–583.
28. Cooke A. Understanding Psychosis and Schizophrenia. Why People Sometimes Hear
Voices, Believe Things That Others Find Strange, or Appear out of Touch with Reality,
and What Can Help. Br Psychol Soc 2017; https://www.bps.org.uk/sites/www.bps.
org.uk/files/Page - Files/Understanding Psychosis and Schizophrenia.pdf (accessed 7
March, 2020).
29. Slade M and Longden E. Empirical evidence about recovery and mental health. BMC
Psychiatry 2015; 15: 285.
30. Maddux JE. Positive psychology and the illness ideology: toward a positive clinical
psychology. Appl Psychol 2008; 57: 54–70.
31. Verhofstadt M, Van Assche K, Sterckx S, et al. Psychiatric patients requesting
euthanasia: Guidelines for sound clinical and ethical decision making. Int J Law
Psychiatry 2019; 64: 150–161.
32. Schweitser F, Stuy J, Distelmans W, et al. Assessment of patient decision-making
capacity in the context of voluntary euthanasia for psychic suffering caused by
psychiatric disorders: a qualitative study of approaches among Belgian physicians. J
Med Ethics. Epub ahead of print 3 August 2020. DOI: 10.1136/medethics-2019-105690.
33. Pies R. How ‘objective’ are psychiatric diagnoses?: (guess again). Psychiatry (Edgmont)
2007; 4(10): 18–22.
34. Pasman HRW, Willems DL and Onwuteaka-Philipsen BD. What happens after a
request for euthanasia is refused? Qualitative interviews with patients, relatives and
physicians. Patient Educ Couns 2013; 92(3): 313–318.
22 Science Progress

35. Bolt EE, Snijdewind MC, Willems DL, et al. Can physicians conceive of performing
euthanasia in case of psychiatric disease, dementia or being tired of living? J Med Ethics
2015; 41(8): 592–598.
36. Snijdewind MC, Willems DL, Deliens L, et al. A study of the first year of the end-of-life
clinic for physician-assisted dying in the Netherlands. JAMA Int Med 2015; 175(10):
1633.
37. Vonkel. JAARVERSLAG VONKEL 2019 (Annual Report of the end-of-life
consultation center Vonkel, 2019). http://vonkeleenluisterendhuis.be/teksten/jaarverslag
2019.pdf (accessed 5 June, 2020).
38. Kammeraat M, Kölling P. Psychiatrische Patiënten Bij Expertisecentrum Euthanasie.
(Psychiatric Patients consulting the Center of Expertise in Euthanasia). Den Haag; 2020.
https://expertisecentrumeuthanasie.nl/app/uploads/2020/02/Onderzoeksrapportage-Psyc
hiatrische-Pati%C3%ABnten-Expertisecentrum-Euthanasie.pdf (accessed 15, January,
2021).

Author biographies
Monica Verhofstadt, MA, MSc, holds a Master in Clinical Psychology. Since October 2017, she
joined the Belgian End-of-Life Care Research Group as a doctoral researcher. In the preced-
ing years she did volunteer work at Vonkel, a Belgian organisation dedicated to supporting
patients and their relatives with end-of-life issues. There, she conducted intake interviews
with patients applying for euthanasia and joined the first Belgian research projects on eutha-
nasia requests from and the euthanasia practice regarding patients with psychiatric
conditions.

Kurt Audenaert is Senior full professor in Psychiatry and Forensic Psychiatry, and the Head
of Clinic Adult Psychiatry in the GhentUniversity Hospital (Belgium). He holds e.g., amas-
ter’s in Medical Sciences, in Psychiatry andin Criminology. He also holds a PhD in medical
sciences (functional brain imaging in psychiatry: a functional-psychopathological approach)
and is a trained psychotherapist (family therapy).

Kris Van den Broeck, PhD, is psychologist and behavioural therapist, visiting professor at the
University of Antwerp, Antwerp, Belgium and managing director of the Flemish Psychiatric
Association. He is involved in the training of (future) (general) practitioners and psychia-
trists. His topics of interest are the organisation of (mental) health care, interprofessional col-
laboration amongst health professionals, and appropriate communication towards patients
in care. Ethical issues often take an important place in these themes.

Luc Deliens holds an MA in Sociology, MSc in Human Ecology and PhD in Health
Sciences. He is trained in medical sociology and Professor of Palliative Care Research. Since
2000, he is the founding Director of the End-of-Life Care Research Group of the Vrije
Universiteit Brussel (VUB) and Ghent University, in Belgium (‘‘http://www.endoflifecare.
be’’www.endoflifecare.be).

Freddy Mortier is Full professor of ethics at Ghent University, Belgium. He studied both at
the Ghent University and Paris-Sorbonne and holds a PhD in philosophy at Ghent
University. He is a former member of the Belgian Advisory Committee for Bio-ethics,
Verhofstadt et al. 23

member of Ghent University Hospital Ethics Committee. He is a member of the End-of-

Life Care Research Group (Free University Brussels and Ghent University, Belgium).

Koen Titeca holds a master’s in medical sciences and in Psychiatry and is a trained psy-
chotherapist. He is the head of the Emergency Psychiatry Department in the General
Hospital of Groeninge, Kortrijk (Belgium). He is alsotrained LEIF-physician (Life End
Information Forum) and gives courses regarding ‘euthanasia and psychiatry’ to LEIF-physi-
cians and nurses. He co-authored the Flemish Psychiatric Association’s Guideline on how to
adequately manage euthanasia requests and procedures from patients with psychiatric
conditions.

Dirk De Bacquer, PhD, is a Senior Full Professor in Epidemiology and Biostatistics at the
Department of Public Health and Primary Care, Faculty of Medicine and Health Sciences,
Ghent University, Belgium. He is also theHead of the Epidemiology and Prevention section
and of the Biostatistics Unit, Ghent University, Belgium. He was theFormer Chair of the
Department of Public Health, Ghent University, Belgium, and Fellow of the European
Society of Cardiology.

Kenneth Chambaere is Interdisciplinary Professor of Public Health, Sociology & Ethics of

the End of Life at the End-of-Life Care Research Group of Ghent University & Vrije
Universiteit Brussel (VUB). He has an MSc in Sociology, a Postgraduate in Logic, History
and Philosophy of Science, and a PhD in Medical-Social Sciences. He was a Postdoctoral
Fellow of the Research Foundation Flanders (FWO). Prof. Chambaere’s current research
focusses on three main themes: (1) end-of-life practices, (2) palliative care in and by the com-
munity and (3) end-of-life care for people in vulnerable positions.